<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390305107
Report Date: 07/01/2024
Date Signed: 07/01/2024 11:14:49 AM

Document Has Been Signed on 07/01/2024 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SOLIDUM GUEST HOME 2FACILITY NUMBER:
390305107
ADMINISTRATOR/
DIRECTOR:		SOLIDUM NORMAFACILITY TYPE:
735
ADDRESS:3115 APPLING CIRCLETELEPHONE:
(209) 952-4276
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 6DATE:
07/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Lynn CaoliTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 05/10/2024 . LPA explained purpose of visit to the administrator and staff.

The incident report was regarding a resident (R1) refusing medication and an eviction notice. LPA reviewed incidents reports and R1'S medication administration records (MAR'S). R1'S doctor discontinued the medication on 06/20 /2024. R1'S is still living at the facility, valley mountain regional is looking for another placement. All incidents were reported on time and to the correct departments. Photo's taken of current medication.

Per California Code of Regulations, Title 22 no deficiencies were observed or cited during today's case management inspection.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1